Disability Insurance

This Ruling supersedes, only in states within the Fourth Circuit (North
Carolina, South Carolina, Maryland, Virginia and West Virginia), Social
Security Ruling (SSR) 88-13, Titles II
and XVI: Evaluation of Pain and Other Symptoms.

PURPOSE: The purpose of this interpretive Ruling is to supersede
SSR 88-13 in the Fourth Circuit and to
transmit to adjudicators the Fourth Circuit's standard on the evaluation
of pain. In a recent decision in Hyatt v. Sullivan, the
Court of Appeals for the Fourth Circuit found that
SSR 88-13 was consistent with Fourth
Circuit law. However, the court was concerned that some adjudicators could
have read SSR 88-13 in a manner
consistent with circuit precedent, because the instruction not only
contained some language from the obsoleted SSR 82-58 (which in part had
been earlier held invalid by the court) but also because it was a
reiteration of certain aspects of the policy on the evaluation of pain and
other symptoms that the court previously had invalidated.

Therefore, the Court of Appeals held that in order to conform with Fourth
Circuit law, the Social Security Administration (SSA) must issue
instructions clearly expressing the circuit rule regarding pain (i.e.,
that objective findings of the pain's intensity, persistence and effect on
an individual's work capacity are not required to find disability) to
eliminate possible confusion on the part of adjudicators. To this end, the
court held that SSA could amend SSR
88-13, "to make it clear that it is not a reiteration of previous
policy and that it has a more current effective date." This Ruling, which
simply amends the purpose and effective date sections of
SSR 88-13, is designed to comply with
the court's order in the Hyatt case.

FOURTH CIRCUIT STANDARD: Once an underlying physical or ental
impairment that could reasonably be expected to cause pain is shown by
medically acceptable objective evidence, such as clinical or laboratory
diagnostic techniques, the adjudicator must evaluate the disabling effects
of a disability claimant's pain, even though its intensity or severity is
shown only by subjective evidence. If an underlying impairment capable of
causing pain is shown, subjective evidence of the pain, its intensity or
degree can, by itself, support a finding of disability. Objective medical
evidence of pain, its intensity or degree (i.e., manifestations of the
functional effects of pain such as deteriorating nerve or muscle tissue,
muscle spasm, or sensory or motor disruption), if available, should be
obtained and considered. Because pain is not readily susceptible of
objective proof, however, the absence of objective medical evidence of the
intensity, severity, degree or functional effect of pain is not
determinative.

INTRODUCTION: Symptoms such as pain, shortness of breath,
weakness, or nervousness are the individual's own perceptions of the
effects of a physical or mental impairment(s). Because of their subjective
characteristics and the absence of reliable techniques for measurement,
symptoms (especially pain) are difficult to provide, disprove, or
quantify. This policy interpretation explains the need for a sound medical
basis for the disability decision and emphasizes the importance of the
consideration to be given to symptoms in the evaluation of impairment
severity and functional limitation.

POLICY INTERPRETATION: Proper consideration of the effect of pain
and other symptoms on an individual's ability to work is an important part
of the disability evaluation process. Because pain is subjective and not
susceptible to measurement by reliable techniques, the existence of pain
and the extent to which pain affects the individual's functional ability
to do basic work activities are difficult to evaluate.

Need to Establish a Medically Determinable Impairment

Pain cannot be found to have a significant effect on a disability
determination or decision unless medical signs or laboratory findings show
that a medically determinable physical or mental impairment is present
that could reasonably be expected to produce the pain alleged.

When medical signs and laboratory findings do not substantiate any
physical impairment capable of producing the alleged pain (and a favorable
determination cannot be made on the basis of the total record), the
possibility of a mental impairment as the basis for the pain should be
investigated.

Consideration of Pain in Establishing the Severity of a Medically
Determinable Impairment

Once a medically determinable physical or mental impairment is
documented, the effects of pain must be considered at each step of the
sequential evaluation process.

1. IS THE CONDITION SEVERE?

To be found disabled, an individual must have a medically determinable
severe impairment(s). To be considered severe, the impairment or
combination of impairments must have more than a minimal effect on the
individual's physical or mental abilities to do basic work activities. In
determining whether an impairment(s) is severe, full consideration is to
be given to all material evidence, including signs, symptoms (such as
pain), and laboratory findings. Objective findings may confirm that the
individual has a severe impairment. If they do not, the degree of pain
must be considered. Where the degree of pain reported is reasonably
consistent with the objective medical evidence presented, the conclusion
that the impairment is severe must be based on a determination that the
total evidence, including the alleged pain, establishes that the
individual's ability to do basic work activities is affected to more than
a minimal degree. However, where the degree of pain alleged is
significantly greater than that which can be reasonably anticipated based
on the objective physical findings, the adjudicator must carefully explore
any additional limitation(s) imposed by the pain on the individual's
functional ability beyond those limitations indicated by the objective
medical evidence before any conclusions about severity can be reached.

2. ARE THE FINDINGS ABOUT THE INDIVIDUAL'S IMPAIRMENT IDENTICAL TO THOSE
IN THE LISTING?

Disability may be established on a medical basis alone if the criteria of
an impairment cited in the Listing of Impairments are met. Some listed
impairments include symptoms among the requisite criteria. For example,
Listing 1.04 requires a history of joint pain and stiffness. When a
symptom, such as pain, appears as a criterion (as in Listing 1.04), it is
ordinarily essential only that the symptoms be present in combination with
the remaining criteria. Unless specifically indicated (as in Listing
1.04A, which requires that abduction of both arms at the shoulders,
including scapular motion, be restricted to less than 90 degrees),
quantification or evaluation of the intensity or of the functionally
limiting effects of that symptom is not required to determine whether the
documented findings meet the requisite criteria.

3. ARE THE FINDINGS ABOUT THE INDIVIDUAL'S IMPAIRMENT(S) EQUIVALENT TO
THOSE FOR AN IMPAIRMENT(S) IN THE LISTING?

In considering whether documented findings and symptoms are of equivalent
severity to the requisite findings and symptoms of a listed impairment,
look to see whether the set of symptoms, signs, and findings present are
of equal or greater significance than those in the listed criteria.
However, an alleged or reported increase in the intensity of a symptom
cannot be substituted no matter how severe, for a missing or deficient
sign or finding to elevate impairment severity to equivalency to the
listed impairment. For example, a history of severe, persistent joint pain
cannot be substituted for the required x-ray evidence of either joint
space narrowing or bony destruction (with erosions or cysts) in Listing
1.04 to draw a conclusion of "equal."

Consideration of the Intensity and Persistenceof Pain in
Determining Functional Capacity

If the listing is not met or equaled, a residual functional capacity
(RFC) assessment is necessary to determine the effects of the impairment,
including any additional limitations imposed by pain, on the claimant's
capacity to perform former work or other work. Medical history and
objective medical evidence such as evidence of muscle atrophy, reduced
joint motion, muscle spasm, sensory and motor disruption, are usually
reliable indicators from which to draw reasonable conclusions about the
intensity and persistence of pain and the effect such pain may have on the
individual's work capacity. Whenever available, this type of objective
medical evidence must be obtained and must be considered in reaching a
conclusion as to whether the individual is under a disability.

There are situations in which an individual's alleged or reported
symptoms such as pain, suggest the possibility of a greater restriction of
the individual's ability to function than can be demonstrated by objective
medical evidence alone. In such cases, reasonable conclusions as to any
limitations on the individual's ability to do basic work activities can be
derived from the consideration of other information in conjunction with
medical evidence. This is consistent with court decisions which require
that statements of the claimant or his/her physician as to the intensity
and persistence of pain or other symptoms which may reasonably be accepted
as consistent with the medical signs and laboratory findings are to be
included in the evidence to be considered in making a disability
determination.

When the claimant indicates that pain is a significant factor of his/her
alleged inability to work, and the allegation is not supported by
objective medical evidence in the file, the adjudicator shall obtain
detailed descriptions of daily activities by directing specific inquiries
about the pain and its effects to the claimant, his/her physicians from
whom medical evidence is being requested, and other third parties who
would be likely to have such knowledge.

In developing evidence of pain and other symptoms, it is essential to
investigate all avenues presented that relate to subjective complaints,
including the claimant's prior work record and information and
observations by treating and examining physicians and third parties,
regarding such matters as:

1. The nature, location, onset, duration, frequency, radiation, and
intensity of any pain;

In evaluating a claimant's subjective complaints of pain, the adjudicator
must give full consideration to all of the available evidence, medical and
other, that reflects on the impairment and any attendant limitations of
function.

The RFC assessment must describe the relationship between the medically
determinable impairment and the conclusions of RFC which have been derived
from the evidence, and must include a discussion of why reported daily
activity restrictions are or are not reasonably consistent with the
medical evidence.

In instances in which the adjudicator has observed the individual, the
adjudicator is not free to accept or reject the individual's subjective
complaints solely on the basis of such personal observations. Rather, in
all cases in which pain is alleged, the determination or decision
rationale is to contain a thorough discussion and analysis of the
objective medical evidence and the nonmedical evidence, including the
individual's subjective complaints and the adjudicator's personal
observations. The rationale is then to provide a resolution of any
inconsistencies in the evidence as a whole and set forth a logical
explanation of the individual's capacity to work.

EFFECTIVE DATE: This Ruling is effective on publication in the
FEDERAL REGISTER, but the policy explained herein applies to claims
decided on or after July 20, 1988, the date of publication of
SSR 88-13. This Ruling is being reissued
now to address concerns expressed in the Fourth Circuit's recent decision
in Hyatt v. Sullivan that any prior Agency instructions on
pain which may have been interpreted as contrary to the law of the Fourth
Circuit must be disregarded.

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